Old (2009), but with interesting contents regarding THR
Published: 03 November 2009
Link to publication: http://www.harmreductionjournal.com/content/6/1/29
Carl V Phillips
Nicotine is so desirable to many people that when they are given only the options of consuming nicotine by smoking, with its high health costs, and not consuming nicotine at all, many opt for the former. Few smokers realize that there is a third choice: non-combustion nicotine sources, such as smokeless tobacco, electronic cigarettes, or pharmaceutical nicotine, which eliminate almost all the risk while still allowing consumption of nicotine. Widespread dissemination of misleading health claims is used to prevent smokers from learning about this lifesaving option, and to discourage opinion leaders from telling smokers the truth. One common misleading claim is a risk-risk comparison that has not before been quantified: A smoker who would have eventually quit nicotine entirely, but learns the truth about low-risk alternatives, might switch to an alternative instead of quitting entirely, and thus might suffer a net increase in health risk. While this has mathematical face validity, a simple calculation of the tradeoff — switching to lifelong low-risk nicotine use versus continuing to smoke until quitting — shows that such net health costs are extremely unlikely and of trivial maximum magnitude. In particular, for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source and never quitting it. Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him. Similarly, a strategy of waiting for better anti-smoking tools to be developed, rather than encouraging immediate tobacco harm reduction using current options, kills more smokers every month than it could possibly ever save.
While it is logically possible that lowering the risk from an exposure could increase population risk, the (1-x)/x calculation shows this is not plausible for THR. The suggestion that, despite the lower population risk, many individuals might still face greater risk is also logically possible, but the calculation presented here shows that this is not a substantial practical worry.
On average, someone who would die from smoking who is going to take more than a month to quit entirely (or will experience relapses that will have a similar health impact – probably roughly a total of one month worth of days) will have less total health risk by switching immediately, even if he never quits the alternative product. The typical pattern of even dedicated quitters, starting and stopping smoking for a year or two, will cause much more risk than switching to a low-risk alternative. Moreover, even an average smoker who was going to successfully quit after only a week or two more will suffer only a tiny net increase in physical health risk from switching now, a change so trivial compared to the net benefits of switching for smokers who will not quit for years or ever that it is clearly inconsequential.
The practical implications of this analysis do not change based on plausible variations in the input parameters, including the risk from using ST. Even if we use a completely implausible high risk from ST use, say that it causes 10% of the risk of smoking, then if an average smoker would have taken ten months to quit entirely, he would have had lower risk had he switched immediately. The break-even might be as low as about half a year – recall the conservative assumption built into the calculation. Thus, even discovering that ST use is an order of magnitude worse than the ample current evidence suggests would not fundamentally change the implications of the analysis.
Since this analysis is based entirely on mortality risk, it ignores other contributions to welfare. The reason that current smokers have not already quit, in spite of the health benefits of doing so, is that it would have resulted in substantial costs to them and, similarly, whenever a smoker chooses to switch it implies that there is a net welfare benefit (compared to either smoking or abstinence) to using the alternative product. This welfare gain from switching rather than quitting probably dwarfs the welfare implications of the mortality risk from low-risk products, though quantifying that is beyond the present scope.
Finally, it is worth noting that someone who switches from smoking to a low-risk alternative still has the option of quitting entirely, lowering his risk slightly more still. Indeed, there is reason to believe that eventually quitting alternative products is easier. This means that even the young smokers who might have been better off with several more months of smoking rather than a lifetime of THR product use stand a good chance of quitting entirely anyway (if they decide that the benefits of consumption are outweighed by the benefits of quitting), further favoring the option of switching now. Even those smokers who cannot afford another day of smoking but fortunately switch just in time (who are likely from older demographics that are the primary target for THR) could then survive long enough to quit nicotine entirely.
Many of the claims about health risk made to try to discourage the adoption of THR have been proven to be out-and-out false. This includes the « total social health risk will increase » claim. The present analysis does not relegate the « some people would be stopped from quitting entirely and thus have worse health outcomes » claim to universal falsehood – it will still inevitably be true for a very few individuals. But this is common in public health interventions, from automobile safety equipment to vaccines – the net social effects are overwhelmingly beneficial, though some people (who cannot be identified ex ante, and often not even ex post) suffer net harm rather than benefit. The analysis shows that only a tiny portion of all future quitters will be quitting soon enough that they would have higher expected risk by switching immediately. Moreover, the net increase in expected risk even for those individuals would be extremely small, and the net welfare effects would still be positive. Clearly, then, the claim does not represent a sufficient concern to override the huge net expected social benefit, to say nothing of the ethical requirement that smokers be informed about their options. The claim is thus relegated to being a distraction from rational and honest discourse on the subject, not a contribution to it.
This calculation emphasizes the cost of delaying the adoption of THR at the individual level also: Those of us who promote THR are familiar with smokers who, upon learning about THR, insist that they do not need to consider that option because they will eventually be exercising the « perfect » option of quitting anyway. But many such individuals never quit, and almost none quit in time for it to be a healthier choice. Similarly, each additional month that anti-THR activism keeps a potential switcher from learning about THR is more likely to kill him than is a lifetime of using ST or another low-risk nicotine product. To put it bluntly, anti-THR activism and disinformation do far more damage to public health than smokeless tobacco, electronic cigarettes, or other THR products ever could.
Since THR can be self-tailored and requires no clinical or government intervention, it does not matter that there may be smokers for whom no low risk product is an adequate substitute or that there is no political will to actively endorse it. THR can be adopted by individuals who do find an acceptable substitute, and likely will be widely adopted if smokers were simply given accurate information. The usual explanation for the lack of such information is that anti-tobacco extremists promulgate disinformation it and then even the opinion leaders who are genuinely concerned about public health repeat the inaccurate claims because they have been misled. But an alternative explanation is misplaced optimism on the part of the public health leaders: That is, many may not be misled by the disinformation about THR, but may genuinely believe that most smokers will successfully quit using nicotine very soon or that a perfect new anti-smoking method, policy, or product will be developed and cause everyone to quit soon, reducing their risks more than THR would. The present analysis shows just how overly-optimistic that belief needs to be in order to justify the failure to immediately promote THR using current technology.
Whatever the explanation for it, the present analysis shows that anti-THR activism is deadly. Hiding THR from smokers, waiting for them to decide to quit entirely or waiting for a new anti-smoking magic bullet, causes the deaths of more smokers every month than a lifetime using low-risk nicotine products ever could.
Full text: 1477-7517-6-29